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Gastroesophageal Reflux Disease (GERD)

Most people experience heartburn at some point in their lives. Often this condition is treated easily with over the counter medications or lifestyle changes. Some people, though, experience symptoms that do not ease with treatment and can cause serious complications.

What is GERD?

Gastroesophageal reflux disease, or GERD, is a disorder of the digestive system. It involves a ring of muscle called the lower esophageal sphincter (LES). In normal digestion, this ring opens to allow food into the stomach and closes to prevent anything from flowing back up into the esophagus. When this ring is weakened or relaxes at the wrong times, it allows stomach acids to flow back up into the esophagus. This is called reflux.

This is the same thing that causes heartburn or acid reflux pain in many people after heavy or spicy meals. GERD, however, is a severe and chronic condition involving acid reflux than can lead to severe complications.

Gastroesophageal reflux disease is thought to affect 10-20% of the population, with approximately 7% suffering from symptoms daily.

Symptoms of GERD

Occasional heartburn is generally not too concerning, however, if one has any of the following symptoms, they may want to talk to their physician about GERD:

Heartburn that persists for two or more weeks despite the use of over the counter medication.

Heartburn that is not relieved by over the counter medication.

Worsening pattern or severity of heartburn.

Waking at night with heartburn.

Difficulty swallowing when experiencing heartburn.

Hoarseness or worsening of asthma after meals.

Unexplained loss of appetite and/or weight.

Increasingly frequent use of OTC medications.

Heartburn symptoms that interfere with daily activities and lifestyle.

Heartburn or Acid Reflux

The most common symptom of GERD is heartburn. Heartburn is often described as a burning pain behind the breastbone. It often occurs after eating and can last anywhere from a few moments to hours. Heartburn can also be described as a burning in the throat and a feeling of a hot or acidic liquid in the back of the throat. Some people describe the feeling as having food stuck in the back of the throat or in the chest.

Less Common Symptoms

Most commonly people with GERD experience symptoms including heartburn, nausea and regurgitation. Other symptoms can include a dry, unexplained cough, laryngitis or hoarseness, sudden increases in saliva, bad breath, earaches and a worsening of asthma. Additional symptoms include recurrent pneumonia, painful swallowing and chest pain. Individuals with GERD may experience any or all of these symptoms.

In infants, symptoms include vomiting and coughing. GERD can also cause a failure to thrive and breathing problems in infants.

Triggers of GERD

GERD symptoms can be triggered by several different factors and not all of them are the same for every person.

Fatty foods are among the top three triggers for GERD suffers. This is because food that is high in fat sits longer in the stomach and causes the production of high levels of acid. Fatty and greasy foods also contribute to the relaxation of the lower esophageal sphincter, meaning all that extra acid is more easily able to flow back into the esophagus.

Similarly, eating large meals causes the stomach to expand, putting pressure on the same ring of muscle. This can cause symptoms to develop even with foods that are not typically triggers for someone. Late night meals are also listed among the top three triggers of symptoms because lying down makes digestion more difficult.

There are several foods that are commonly identified as triggers. However, these are not the same for each individual. Perhaps the best way to identify exactly which foods and beverages are triggers is by keeping a food journal for several weeks and noting any symptoms that arise.

The most commonly identified foods that trigger GERD symptoms include:

Alcohol.

Spicy foods, garlic and black pepper.

Chocolate.

Citrus fruits and juices.

Caffeinated beverages.

Tomatoes and tomato sauces.

Peppermint.

Once again, these are not triggers for every person, just some of the most common. There is no need to avoid them if they do not trigger a certain individual’s symptoms.

Exercise is another common trigger for GERD symptoms. This is because bending, or any other activity that puts pressure on the abdomen can force stomach acids to flow back into the esophagus. Additionally, jarring activities, such as jogging, can trigger symptoms. Exercise and weight loss can ultimately relieve the symptoms of GERD, so rather than giving up on exercise, doctors recommend waiting at least two hours after a meal to exercise.

Medications and supplements can also cause GERD symptoms to flare. Some of these are medications, such as narcotic painkillers, are known to relax the lower esophageal sphincter. Again, not everyone experiences the same reaction to these medications.

Causes of GERD

There is no single cause of gastroesophageal reflux disease. Some people develop the condition for unknown reasons. There are some identified contributing factors, however. These include physical abnormalities in the body, such as hiatal hernias, and certain syndromes or conditions that cause the acidity of stomach acids to be higher than normal.

Pregnancy, obesity, smoking are also factors that contribute to GERD. The presence of gallstones and obstructive sleep apnea has been linked to the condition, but remain unproven as contributing factors.

The use of certain medications, such as prednisolone, has been linked to GERD as well. Additionally a study found that about 40% of GERD suffers involved in the study had an infection of H. pylori.

Underdeveloped digestive systems are thought to be the reason some infants have the condition. Fortunately, most children outgrow it as they age.

Complications of GERD

Gastroesophageal reflux disease, when left untreated, can cause a variety of complications. Esophagitis, which is the inflammation of the esophagus is caused by the chronic exposure to caustic stomach acids. This inflammation can lead to more severe complications such as narrowing of the esophagus, ulcers, bleeding and Barrett’s esophagus.

The esophagus can form scar tissue to repair the damage to cells caused by the exposure to stomach acid. This can narrow the passageway of the lower esophagus, causing difficulty swallowing. In addition to scarring, stomach acids severely erode the tissues in the esophagus. This can cause open sores, or ulcers. These ulcers are painful, can cause bleeding and make swallowing difficult.

Sometimes, a condition called Barrett’s esophagus is observed. This condition causes changes in the color and make-up of the tissues in the esophagus. Barrett’s esophagus is associated with a higher risk of cancer.

Diagnosis and Testing

Most often a physician will prescribe medication to control GERD based on the patient’s description of symptoms alone. Occasionally, additional testing may be performed, especially when the patient does not respond to medication, dietary and lifestyle changes. These tests can include an upper GI endoscopy, esophageal tests and upper gastrointestinal series.

An upper gastrointestinal endoscopy involves the use of a scope to view the linings of the stomach, esophagus, and the first part of the small intestine. Esophageal tests are performed to observe and monitor how well the muscles that move food are performing and to monitor the presence and duration of acid in the esophagus. An upper gastrointestinal series is performed to identify other problems that may be causing GERD.

Treatment of GERD

Lifestyle and dietary changes, combined with medications, are often the only treatments needed to control GERD. These changes include weight loss, avoidance of trigger foods and beverages, and avoiding meals several hours before bedtime. Eating smaller and more frequent meals can relieve symptoms. Additionally, raising the head of the bed by six to eight inches often relieves nighttime symptoms. Patients who don't respond to lifestyle, dietary and medication treatments may consider surgical treatment.

Identifying Triggers

Identifying and avoiding triggers can be invaluable when managing the symptoms of GERD. People may be surprised to find exactly what triggers their symptoms. Keeping a detailed journal will help people identify exactly which foods, beverages, medications and activities trigger symptoms.

This journal should include very detailed information. For example, if someone has red wine with dinner, they should note “red wine” rather than simply writing “wine” or “alcohol.” Additionally, one should note exactly which times they ate as well as when any symptoms occur.

Medications For GERD

Antacids, such as Rolaids, provide fast, short term relief by neutralizing stomach acidity. These medications are available over the counter and are often a first response to symptoms of GERD.

H2 blockers, such as Zantac 75, can be obtained over the counter as well as in prescription strength. These medications reduce the production of stomach acid. They are often used on-demand for fast relief of symptoms and can help to heal the esophagus.

PPIs, or proton pump inhibitors, such as Prevasid, inhibit the production of acid as well. These are more potent and longer lasting than H2 blockers. They are used for long term treatment of GERD and are taken on an empty stomach for prevention of symptoms rather than relief of symptoms. These medications are also more effective for healing the esophagus than H2 blockers.

Prokinetics are sometimes used to treat GERD. These medications cause the stomach to empty faster. The use of these medications is often limited because the side effects they cause however. Antibiotics have been shown to help the stomach empty faster as well, often with fewer side effects than prokinetics.

These medications can be given alone or in combination to relieve and control acid reflux. Since they all work in different ways, often they are used together. For example, H2 blockers or antacids may be used to instantly relieve symptoms until the PPI effects help to lessen the production of acid.

Surgical Treatment

Sometimes, individuals do not respond to medication. When diet and lifestyle changes, combined with medication do not work, GERD surgery may be an option. Additionally, GERD surgery may be performed if the condition is causing other complications.

Most commonly, fundoplication is the surgery performed to treat the condition. In this procedure, a surgeon wraps and stitches the whole or part of the upper part of the stomach around the lower part of the esophagus. This procedure is the most effective surgical treatment for GERD.

This surgery carries the risks of any other surgical procedure, including bleeding and infection as well as the following:

Difficulty swallowing.

Failure, meaning that the esophagus slides out of the part of the stomach wrapped around it, which causes the LES to be unsupported.

Returning heartburn.

Excessive gas.

Common risks and complications of anesthesia.

Side effects experienced after the procedure can include returning heartburn, the inability to belch, excessive flatulence and difficulty swallowing. Some patients may still have to take medications for GERD and occasionally a repeat operation is needed.

Endoscopic Surgical Treatment

Another surgical treatment for GERD is a minimally invasive endoscopic procedure. Using small tools attached to the end of an endoscope, a surgeon can bind the top of the stomach to the esophagus, providing the benefits of open body fundoplication without the risk of major surgical complications.

Stitches can also be placed in the lower part of the esophagus to strengthen it.

Additional treatment may involve radiofrequency treatment. During this procedure, high energy radio waves are emitted through endoscopy and directed at the lower esophagus. This causes the esophagus to create scar tissue. More than one procedure may be needed to relieve symptoms.

These procedures can vastly reduce the severity of GERD symptoms. They may not relieve all of the symptoms of GERD, however, and may people still need to take prescription medication afterwards. Some procedures can be less effective than fundoplication but carry significantly less risk of complication.

Considerations

Any patient experiencing chest pain should immediately seek medical help to rule out other causes of the pain, such as heart attack. Because chest pains are commonly mistaken as heartburn or indigestion, if one is experiencing chest pain and is unsure whether to relate it to heartburn or angina, immediate emergency medical assistance should be sought.

Another kind of reflux, called extraesophageal reflux can also occur. This condition generally causes laryngeal and respiratory symptoms without heartburn and is commonly called “silent reflux.”

Whether a person is experiencing weekly or daily heartburn, even if well managed by over the counter antacids or medications, they should seek the advice of their physician. While heartburn may seem like a minor condition to complain about, untreated GERD can lead to very severe complications.